Lymph Node–Positive Bladder Cancer Treated With Radical Cystectomy and Lymphadenectomy: Effect of the Level of Node Positivity

Abstract

Background The extent of lymphadenectomy needed to optimize oncologic outcomes after radical cystectomy (RC) for patients with regionally advanced bladder cancer (BCa) is unclear. Objective Evaluate the effect of the location of lymph node metastasis on recurrence-free survival (RFS) and cancer-specific survival (CSS) for patients undergoing RC with a mapping pelvic lymph node dissection (PLND). Design, setting, and participants A study of 591 patients undergoing RC with mapping PLND was completed between 2000 and 2010. Median follow-up was 30 mo. Intervention RC with mapping PLND. Measurements We evaluated the impact of lymph node involvement by location on disease outcomes using the 2010 TNM staging system. Survival estimates were described using Kaplan-Meier methods. Gender, age, pathologic stage, histology, number of positive nodes, node density, use of perioperative chemotherapy, and grade were evaluated as predictors of RFS and CSS using multivariate Cox proportional hazard regression. Results and limitations Overall, 114 patients (19%) had lymph node involvement, and 42 patients (7%) had pN3 disease. On multivariate analysis, the number of positive lymph nodes (one or two or more) was significantly associated with increased risk of cancer-specific death (hazard ratio [HR]: 1.9 [95% confidence interval (CI), 1.04–3.46], p = 0.036; versus HR: 4.3 [95% CI, 2.25–8.34], p < 0.0005). Positive lymph node location was not an independent predictor of RFS or CSS. Five-year RFS for pN3 patients undergoing RC with PLND was 25% (95% CI, 22–54). This finding was not statistically different from our pN1 and pN2 patients (38% [95% CI, 22–54] and 35% [95% CI, 11–60], respectively). This study is limited by the lack of prospective randomization and a control group. Conclusions The outcome for patients with involved common iliac lymph nodes was similar to the outcome for patients with primary nodal basin disease. These data support inclusion of the common iliac lymph nodes (pN3) in the nodal staging system for BCa. Lymph node location was not an independent predictor of outcome, whereas the number of positive lymph nodes was an independent predictor of worse oncologic outcome (pN1, pN2). Further refinements of the TNM system to provide improved prognostication are warranted.

Early Oncologic Failure after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

“…Current imaging techniques lack adequate sensitivity and specificity, especially in low-volume metastatic disease. Moreover, it has been shown that in patients with presumably organ confined disease; micrometastatic disease was detected using RT-PCR studies in up to one third of patients with histologically negative lymph nodes 25,26 . Similarly, patients with colorectal, ovarian and urothelial cancers with local relapse, port site seeding and early metastasis after laparoscopic surgery have been previously reported 21,27 .…”

The impact of female gender on bladder cancer-specific death risk after radical cystectomy: a meta-analysis of 27,912 patients

“…1), 541 and 715 articles were excluded in the careful primary and further screening. Next, we retrieved the full text of remaining 119 articles and finally selected 17 studies that conformed to the eligible criterion [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. The baseline characteristics of the 17 studies are described in Table 1.…”

Extent of pelvic lymph node dissection in penile cancer may impact survival

“…The benefits of more extended PLND's have been previously studied in patients treated with radical cystectomy. A more comprehensive PLND, both in pN0 and pN+ patients, has been shown to be associated with improved clinical outcomes in bladder cancer patients treated with radical cystectomy [17][18][19][20][21][22][23]. It has been suggested that at least in the setting of bladder cancer, extended PLND can lead to cure in some patients with metastasis or micrometastasis to limited node [17].…”